Fire the Medical Schools Council if you want more GPs
BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g6245 (Published 28 October 2014) Cite this as: BMJ 2014;349:g6245All rapid responses
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A response from a final year medical student with an interest in General Practice
In response to this misguided article, I would suggest that the Medical Schools council has much wrong with it, but the criticism within this article appears pernickety. The MSC may want to be a tad more representative of primary care, but it is, and absolutely should be, totally irrelevant in terms of recruiting GPs. The last thing medical schools need in another criterion to try and look at for admissions. Becoming a Doctor should be first, thinking of a speciality second.
In response to the other authors, the world is changing and recruitment is not primarily about 7 days working (this is and should rightly be coming in some form, it is good for patients) or renumeration, and attracting people to a "easy life". GPs have always worked hard as far as I can tell.
Job satisfaction is the key, and that can be delivered in a progressive system. If GPs could train in both GP and a different specialty at the same time. This would increase the attractiveness of the profession many fold. People can currently train part time, why can't they train part time in two specialties for longer, more flexibly and they be able to the rewards of this in a more varied and flexible career, they would also be able act as bridges between primary and secondary care. Something which would benefit everyone. This is the solution to the recruitment "crisis" and they Royal College should act on immediately
Competing interests: No competing interests
The cross political party aim to increase the number of doctors working as GPs in the United Kingdom comes from a real drive of care in the community (along with predictable rhetoric to obtain votes). In the wake of recent high profiles campaigns from the BMA “Your GP cares campaign” (1) and the RCGP “Put Patients First” (2) some of the challenges facing general practice are becoming widespread known by the public. The workload of GPs has increased, with relative income decreasing. A recent BMA quarterly tracker survey (3) revealed that 72.8% of GPs think their workload is unmanageable and that GPs had lowest scores for work life balance and morale than any of the other doctors who responded. This is a difficult climate to be a GP supervising medical students attempting to encourage them into this field of medicine.
As Mr Wakefield wrote it has been reported that the UK Government aims to have around 50% of medical graduates working as GPs however a smaller percentage of medical students actually plan a career in general practice. (4) Across the United Kingdom that there are many more training jobs numbers in general practice than other specialities and for the first time ever an extra third round of GP recruitment occurred in England in 2014 aiming to fill training posts – despite this extra round some training jobs in general practice remained vacant. (5)
As a GP with the privilege of supervising medical students on an ad hoc basis during their primary care attachments (often one to one teaching) I am left in a slight quandary when discussing their career choices. I estimate that approximately 50% of the medical students I teach are completely undecided about their career path and roughly 20% mention they want to (or have not ruled out) becoming a GP. This is of course purely my recollection of what medical students reported verbally to me (they may have an agenda to make their placement easier) however it leaves me as a supervisor in a difficult position about guiding them to maximise their career opportunities.
If an undergraduate is undedicated about their career path and asks my advice I mention the above facts and suggest they consider tailoring their CV away from general practice. This advice is solely based on supply and demand - if a speciality such as general practice has many more training jobs relative to other specialities and is struggling to recruit to these training jobs the undecided medical student is likely to have an opportunity to train as a GP in future. However if the undecided medical student tailors their CV towards primary care at this stage they are potentially unintentionally ruling out opportunities to train in other specialities.
It is of interest when I ran a popular search engine at the time of writing with the term “medical student uk” on page 1 a link encouraging medical students to gain student membership with the Royal College of Physicians of London was prominent whereas no such RCGP link encouraging student membership was present.
The career as a GP has the potential to be extremely rewarding diverse career with many job opportunities in the community, doctoring at sporting events, the options to work as a GP with a specialist interest and the advantage of not being tied down to having to live close to a tertiary hospital. Rather than continuously stressing the ever increasing workload in general practice I strive to lead by example, inspiring students to follow a rewarding career as a GP.
1 Your GP cares campaign. BMA http://bma.org.uk/working-for-change/your-gp-cares last accessed 25/11/14
2 Put Patients First: Back General Practice. RCGP http://www.rcgp.org.uk/campaign-home.aspx last accessed 25/11/14
3 BMA quarterly tracker survey. Current views from across the medical profession. Quarter 3: July/August 2014. http://offlinehbpl.hbpl.co.uk/NewsAttachments/PGH/BMA_quarterly_report.pdf last accessed 25/11/14
4 Wakeford, R., 2014. Fire the Medical Schools Council if you want more GPs. BMJ, p. 349:g6245. http://www.bmj.com/content/349/bmj.g6245 last accessed 25/11/14
5 Millet D. Third round of GP trainee recruitment cost £113,000 to fill 72 posts. GP Online. November 2014 http://www.gponline.com/third-round-gp-trainee-recruitment-cost-113000-f... last accessed 25/11/14
Competing interests: No competing interests
Goodenough published his report into medical school education in1944. He recommended that there should 'be a bias towards General Practice'
70 years later Wakeford has exposed an ongoing institutional bias towards hospital based narrow specialties.
Career choices are also influenced by Foundation training. Foundation trainees apply for specialty training towards the end of their first placement in Foundation year 2. The Collins report recommended that all trainees should have a community based placement as part of their broad programme experience. Only 30% of trainees have this opportunity in Scotland.
I wonder if Wakeford would cast a critical eye over the composition of our Foundation Boards and the proportion of Foundation tutors that are GPs?
Competing interests: Frontline GP concerned that too few medical students choose GP as their first choice vocation
Surely the answer to the GP shortage is obvious? Increase the remuneration relative to other specialisms until the desired recruitment levels are met. This is standard practice in any industry where there is unmet demand for labour.
Competing interests: I am a GP
The current recruitment crisis into General Practice has prompted many authors, most recently Mr. Richard Wakeford1, to speculate why medical students are not turning to Primary Care for their career. However, there is a notable absence of any published work from the student perspective.
Mr. Wakeford’s argument focused on the content of medical school recruitment websites and representation of General Practice in medical training. It is our experience that choosing your medical speciality is a process that mainly takes place during your time at medical school and (we are told) your foundation jobs. Due to a lack of clinical experience, very few medical students start university with a preference of specialty that endures. Regarding a lack of exposure to primary care1, our own medical school provides 13 weeks of placement in this setting; more than double that for any other single speciality. We therefore think that these factors did not feature heavily in our own decision making. From our point of view, a far more important factor in the recruitment of students into the speciality is the intrinsic attractiveness of the job.
A consultant, though admittedly a physician, once told us that in order to pick a speciality you should become aware of the most mundane aspect of the job and decide whether you can live with it. For example a student with an interest in ENT would have to come to terms with the syringing of innumerable ears. It seems to us that a General Practitioner’s staple of reassurance, safety-netting and discharge would provide us with comparatively less job satisfaction than specialities that deal with the more severely unwell. Alongside this there seems to be an ever increasing amount of pressure put on GPs to not miss the ‘big diagnoses’, take for example the recent news story which scrutinised GPs for missing lung cancer2, which was not fully backed up by the paper which it was drawing on3.
In addition, it is our impression that GPs are expected to adhere to an increasing number of strict guidelines, even more so than doctors in hospital specialities. Whilst we appreciate the benefit of evidence-based population-wide guidelines, we find this algorithmic approach too restrictive and uninteresting.
Historically General Practice has had a highly attractive job description, with sociable working hours and strong doctor-patient relationships. We feel that this has changed over the years, an opinion that has been voiced by many of the GPs we have spent time with. For the former, the 7-day week proposal outlined by David Cameron at the Conservative Party Conference would largely eliminate this comparative benefit. The latter has been eroded by ever-increasing time constraints on appointments and fewer patients having a named doctor to build rapport with over time.
More than ever GPs have to take on managerial responsibilities, from positions on CCGs to having to consider budgets in their everyday prescribing. We believe that few medical students embark on their career wanting or expecting management to be such a large part of their working life.
It can’t be denied that more medical students need to be persuaded to undertake a career in General Practice, however we do not agree that blame can be laid solely at the door of the Medical Schools Council. No matter how much the job is promoted or represented, we believe that General Practice is just no longer an attractive career option to most medical students. If you would like us to get interesting in general practice, an entire rethink of the speciality is needed instead of pointless finger pointing about council representation that has very little impact on our daily exposure and experience of general practice, both in and out of medical school.
01. Wakeford, R., 2014. Fire the Medical Schools Council if you want more GPs. BMJ, p. 349:g6245.
02. GPs in UK 'missing opportunities' to spot lung cancer. [Online]
Available at: http://www.bbc.co.uk/news/health-29596645
[Accessed 02 November 2014].
03. Concerns raised about late diagnosis of lung cancer. [Online]
Available at: http://www.ncbi.nlm.nih.gov/pubmedhealth/behindtheheadlines/news/2014-10...
[Accessed 02 November 2014].
Competing interests: No competing interests
Richard Wakeford correctly criticises medical schools for promoting specialisation and research above primary medical care when attracting students although they might counter that most of these have personal experience as patients of NHS general practice but not specialist medicine.
General practice may offer perverse incentives for some, namely precisely defined working hours, an absence of OOH and a shortened period of training. The best young doctors may prefer a discipline with more commitment.
General practice makes demands on practitioners just as great as but different from those of specialist clinical disciplines. The breadth of activity is unmatched and the continuity of contact is unrivalled. General practice requires its practitioners to form enduring relationships with patents which are both personal and professional. GPs are much more at risk both physically and psychologically.
GPs are also exposed to the financial and administrative risks and burdens common to all businesses. Practice income has stalled for the last decade and GP drawings have declined. They are currently showered with clinically dubious but politically advantageous directives such Dementiagate 1. No wonder morale has suffered. This clearly rubs off on students.
One solution would be to increase practice income thus improving morale, recruitment and retention at a stroke!
1. BMJ 2014;349:g6446
Competing interests: No competing interests
The crisis in GP land cant wait 6 years for new graduates. It cant wait 5 years for new vts completer's. It needs solutions now. As primary care taken on more and more people with multiple serious illness who are now meant to be kept out of hospital I propose a fast track parallel entry for those with proven skills, ie mrcp or equivalent. They can be directed to an enhanced GP year with paid for learning to fill the gaps in a purposeful way that sadly still does not happen in vts schemes (ie no experience in dermatology eye allergies ent pscych can still occur) . This will upset the whole apple cart of deaneries and RCGP bodies however but may lead to a resurgence of the perceived value of the GP that is now routinely rubbished in the media with no defence form our College. There seems to be a movement within NHS England (? and the deaneries) that the learning needs of all primary health care staff form HCA to highly experience people is the same and that GP's are expensive when all the evidence is the opposite
Competing interests: No competing interests
Mr Wakeford makes a direct connection between the bias towards hospital specialties in the undergraduate medical curriculum and the current crisis in GP recruitment. Whilst the medical school curriculum may require rebalancing, he forgets the ‘elephant in the room’. A recent BMA survey showed that three quarters of GPs considered their workload to be unmanageable (http://offlinehbpl.hbpl.co.uk/NewsAttachments/PGH/BMA_quarterly_report.pdf) the comparable figure for hospital consultants was 40%. Just under one half were considering quitting before retirement age. One-quarter of junior doctors are considering retraining in a different specialty and the same proportion are considering working overseas. There has been an even greater proportional exodus from London general practices.
General Practice used to be a popular career choice in days gone by when arguably the medical school curriculum was even more biased towards hospital specialties, and it might be argued that a rigorous basic grounding in medical specialties equips a GP with a necessary breadth of knowledge to practice high quality medicine as we are fortunate to see in this country. Yet GP (and hospital consultant) pay has lagged between comparable professions for many years-how can a young GP expect for example to live near their practice in London or many areas of Southern England, for example? Administrative tasks are particularly onerous in primary care and the misconceived regulatory changes announced by the GMC consultation (http://www.gmc-uk.org/concerns/25346.asp) hardly endear the specialty to those in training.
There aren’t, by and large, major doctor shortages in countries where medical work life-balance and remuneration is better: Australia, Canada and the Netherlands are examples, nor is there a net exodus of doctors from these countries. And I haven’t come across a US trained doctor working in the NHS for many years, though there must be some, somewhere. Has Mr Wakeford considered that improving salaries and working conditions and reducing the heavy hand of GMC regulation may ultimately be far more important than tinkering with medical school education?
Competing interests: No competing interests
Wakeford argues that 'conflicted' medical school councils have an adverse impact on recruitment of medical students likely to become general practitioners1. Whilst the academic ethos of a medical school is clearly important in determining eventual career paths for individual doctors many other influences contribute to career decision making before, during and after undergraduate training2. The failure to fully recruit to UK general practice training this year after an unprecedented third round of selection suggests, however, significant problems with the career itself3.
No national medical training system in the developed world recruits anywhere near 50% of its graduates to general practice. Even in countries with sophisticated primary care systems where earnings are similar between generalists and specialists only about a quarter of recent graduates profess initial interest in a career in general practice4.
In countries like the USA where over three quarters of doctors specialise targeted efforts have been made by some colleges and medical schools to select predominantly those intent as school leavers on a career in general practice. The reasons why this policy does not translate into equivalent numbers of general practitioners relate not only to recognised factors that attract students away from primary care towards some specialties during their training (positive experiences during undergraduate placements, career earnings, status, academic eminence etc) but also to those factors within the medical schools themselves that detract - including denigration of general practice by undergraduate teachers and medical student peers5.This antithesis to general practice within medical schools has also been reported in Canada6, Australia7,the United Kingdom8, Germany9 and Switzerland10.
There is much current focus on selection and training for UK general practice. Student selection to medical school and attitudes to general practice careers among fellow students and staff do play a part in influencing students’ career choice. However it has to be questioned whether it is the training system itself or current perceptions around a career in UK general practice that predominantly influence recruitment. Tinkering with the system may have little impact if the root cause lies in the reputation of the career in both professional and public eyes. General practice currently appeals to a minority of medical graduates. Only through improved understanding of the career drivers in our medical students and young doctors, and including these in more enticing career structures, can primary care have any real prospect of attracting half of all new doctors to its ranks.
References
1. Wakeford R. Fire the Medical School Council if you want more GPs. BMJ 2014; 349:g6245
2. Munro N. Postgraduate attachment to general practice: influence on future career intentions. DPhil. Sussex University. February 2011
3. Rimmer A. One in eight GP training posts vacant despite unprecedented third round of recruitment. http://careers.bmj.com/careers/advice/view-article.html?id=20019782. Accessed 2/11/2014.
4. Svirko E., Goldacre M.J., Lambert T. Career choices of the United Kingdom medical graduates of 2005, 2008 and 2009: Questionnaire surveys Medical Teacher, May 2013, Vol. 35, No. 5: Pages 365-375
5. Pugno, P. A., McGaha, A. L., Schmittling, G. T., DeVilbiss, A. and Kahn, N. B., Jr. (2007), Results of the 2007 National Resident Matching Program: family medicine, Family Medicine, 39, 562-71.
6. Scott, I., Gowans, M. C., Wright, B. and Brenneis, F. (2007), Why medical students switch careers: changing course during the preclinical years of medical school, Canadian Family Physician, 53, 95, 95:e 1-5, 94.
7. Thistlethwaite, J., Kidd, M. R., Leeder, S., Shaw, T. and Corcoran, K. (2008), Enhancing the choice of general practice as a career, Australian Family Physician, 37, 964-8.
8. Munro N & Tavabie A. General practice (GP) foundation training: the antidote to 'badmouthing' of general practice. Educ Prim Care 2010 May;21(3):145-8
9. Natanzon I., Ose D., Szecsenyi J., Campbell S., Roos M. & Joos S. Does GPs' self-perception of their professional role correspond to their social self-image? - A qualitative study from Germany BMC Family Practice 2010, 11:10
10. Buddeberg-Fischer, B., Stamm, M., Buddeberg, C. and Klaghofer, R. (2008b), Young physicians' view on factors that increase the attractiveness of general practice, Gesundheitswesen, 70, 123-8.
Competing interests: No competing interests
Exaggerated estimates of GP consultation rates may discourage GP recruitment
The causes of poor recruitment of medical graduates to general practice are disputed.1,2 Ironically, recruitment is likely to be further discouraged by the Royal College of General Practitioner's (RCGP) current media campaign to obtain increased funding for general practice accompanied by estimates of current GP consultation rates which greatly exceed available estimates from NHS England and Scotland. On 27th May 2014, Rebecca Smith, Medical Editor of the Daily Telegraph, citing Dr Maureen Baker, President of the Royal College of General Practitioners, stated “family doctors are seeing up to 60 patients a day and working round the clock in order to meet growing demand with less funding, medical leaders have warned... Between 2008 and 2012 the number of consultations carried out by GPs in England has risen from 300million to 340million”. On 30th May 2014, in a response from the RCGP to an article in The Times on GP workload by Alice Thomas, Dr Baker stated “it is no surprise that workloads for family doctors are ballooning, the majority of GP’s are now carrying out 40 to 60 patient consultations per day”. On 26th September 2014, Dennis Campbell, Health Correspondent of The Guardian, citing the RCGP in an article on GP waiting times stated “the average number of consultations undertaken by each GP has risen from 9,264 to 10,714 between 2005-06 and 2012-13.'' On 4th November 2014 on BBC News, Health Correspondent Nick Triggle again cited an estimated 340million GP consultations in 2013-14 in NHS England. On 23rd November 2014, in an article on rising GP workload in The Observer, Daniel Boffey, Policy Editor, cited Dr Baker as follows “our research has shown that doctors are routinely having to work 11-hour days and are making between 40-60 patient contacts a day. We now make 340million patient consultations a year, 40million more than 5 years ago”.
While examining trends in NHS performance in NHS England and Scotland before and after Scottish devolution, I obtained data on consultation rates in general practice in both countries. GP consultation rates in NHS England are only available between 1996-97 and 2008-09 from a study carried out by the Q Research GP database in the University of Nottingham on behalf of the NHS Information Centre.3 This compiled data from 602 practices and about 10million patients. In a thirteen year period between 1995-96 and 2008-09 the crude consultation rate for general practitioners (practice consultations, home visits and telephone consultations) rose by 13% from 3.0 to 3.4 consultations per person year. The consultation rate for practice nurses rose by 138% from 0.8 to 1.9 consultations per patient year. Combined consultation rates for GP’s, nurses and other clinicians rose by 55% from 3.9 to 5.5 per patient year. No data on GP consultation rates in NHS England are available after 2008-09.
Allowing for the rise in population, these consultation rates are equivalent to a rise in GP consultations in NHS England of 20% from 145million in 1996-97 to 175million in 2008-09. Projected to 2012-13 at a continuing increase of about one per cent per year, consultations rise to 190 million in 2012-13,56% of the total claimed by the RCGP in that year.
Estimates of GP consultation rates in NHS Scotland are available from 2003-04 to 2012-13, derived from an 8% sample of all Scottish practices contributing to the Practice Team Information study carried out by the Information Services Division of NHS Scotland.4 Between 2003-04 and 2012-13, the estimated number of GP face-to-face consultations in NHS Scotland rose by 4% from 15.626million (95% CI 14.938-16.315) to 16.236million (95% CI 15.499-16.973). These rates are equivalent to GP consultation rates of 3.1 per person year in both 2003-04 and in 2012-13.
Since no data on GP consultation rates are available for NHS England after 2008-09, the author emailed the RCGP on 7th October requesting the source of the data given to the media for 2012-13. The RCGP replied that the estimates were obtained from a report commissioned from management consultants Deloitte entitled “Under Pressure. The funding of patient care in general practice”, published on 2nd April 2014 The report included only projections of all consultations taking place in general practice by a general practitioner, practice nurse or other clinicians between 2008-09 and 2017-18 from regression analysis based on the Q Research GP database between 1995-96 and 2008-09. The projection of 349 million consultations for 2012-13 in the Deloitte report is similar to the 340million consultations cited by the RCGP in comments to the media. Data on annual and daily GP consultations per capita in 2012-13 are not contained in the Deloitte report and appear to have been derived by the RCGP from the Deloitte projections. The RCGP's claim that the 2012-13 Deloitte projection represents GP consultations only appears to be a misrepresentation of the data; the derived annual and daily consultation rates appear similarly distorted. .
As noted above, the estimated 190million GP consultations projected for NHS England in 2012- 13 from the Q Research GP database were carried out by 36,294 Whole Time Equivalent GP’s and represent 5,300 consultations per GP annually. Assuming that each GP works a 5-day week with 6 weeks’ holiday and consults for 230 days annually, he/she would carry out about 23 consultations daily. In NHS Scotland, 16.2million consultations were carried out by 3,735 Whole Time Equivalent GP’s, equivalent to 4,347 consultations annually and about 19 consultations daily. These consultation rates are substantially lower than the 10,714 annual and 40-60 daily consultations claimed by the RCGP in 2012-13.
Assuming a normal distribution of average consultation rates, a small proportion of practices may experience average consultation rates of 40-60 daily. Seasonal and daily variations may also produce peaks in demand but average rates of this magnitude are unsupported by available data from NHS England and Scotland.
Attempts by the author to obtain further information on this issue from the RCGP have failed, apart from the provision of the source of the projected consultation rates in the Deloitte report. An unintended consequence of exaggerated claims of GP consultation rates by the RCGP may be to provide further disincentives to medical practitioners considering a career in general practice.
References
1. Wakeford R. Fire the Medical Schools Council if you want more GPs. BMJ 2014;349:g6245. (28 October)
2. Majeed A. The NHS, not medical schools, is responsible for the crisis in GP recruitment. BMJ 2014;349:g6967. (29 November)
3. Hippisley-Cox J, Vinogradova Y. Trends in consultation rates in General Practice 1995/1996 to 2008/2009: Analysis of the QResearch® database. Final report to the NHS Information Centre and Department of health. Leeds: The NHS Information Centre for health and social care; 2009. Available from: http://www.hscic.gov.uk/catalogue/PUB01077/tren-cons-rate-gene-prac-95-0...
4. GP Consultations / Practice Team Information (PTI) Statistics [internet]. Edinburgh: ISD Scotland; 2013 [cited 2014 Dec 17]. Available from: http://www.isdscotland.org/Health-Topics/General-Practice/GP-Consultations/
Competing interests: No competing interests